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PresMed Australia
Facility By-Laws
Commencement Date: 1 May 2019
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RATIFIED BY: PMA Board, PMA Facility Boards & PMA Facility MAAC’s
DATE: May 2019
REVIEW DATE: November 2021
PREVIOUS REVIEW: 2015, 2015, 2015. 2017
DATE POLICY CHANGES
April 2019
Facility Rules terminology changed to PMA By-Laws
By-Laws completely revised with legal input in preparation for 5 year re-accreditation processes
Accredited Medical Practitioner terminology vs Credentialed Medical Practitioner
September 2017 Updated with Madison Day Surgery and Coffs Day Hospital
Updated title of COO to CEO
November 2015 Updated with Chatswood Private Hospital & closure of
Ophthalmic Surgery Centre & Sydney ENT & Facial Day Surgery Centre
May 2015 New formatting applied throughout
January 2015 Updated with SENT facility
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TABLE OF CONTENTS
1. Preface ........................................................................................................ 6
2. Mission, Vision, Values and Objectives ................................................... 6
Part A – Definitions and introduction ................................................................ 8
3. Definitions and interpretation ................................................................... 8
3.1 Definitions ....................................................................................................................................... 8
3.2 Interpretation ................................................................................................................................. 12
3.3 Meetings ....................................................................................................................................... 12
4. Introduction .............................................................................................. 13
4.1 Purpose of this document ............................................................................................................. 13
Part B – Terms and conditions of Accreditation ............................................ 13
5. Compliance with By-laws ........................................................................ 13
5.1 Compliance obligations ................................................................................................................. 13
5.2 Compliance with policies and procedures .................................................................................... 13
5.3 Compliance with legislation .......................................................................................................... 14
5.4 Insurance and registration ............................................................................................................ 14
5.5 Standard of conduct and behaviour .............................................................................................. 14
5.6 Notifications .................................................................................................................................. 15
5.7 Continuous disclosure .................................................................................................................. 16
5.8 Representations and media .......................................................................................................... 16
5.9 Committees ................................................................................................................................... 16
5.10 Confidentiality ............................................................................................................................... 17
5.11 Communication ............................................................................................................................. 17
6. Safety and quality ..................................................................................... 18
6.1 Admission, availability, communication, & discharge ................................................................... 18
6.2 Surgery ......................................................................................................................................... 19
6.3 Facility, State Based and National Safety Programs, Initiatives and Standards .......................... 19
6.4 Treatment and financial consent .................................................................................................. 20
6.5 Patient Records ............................................................................................................................ 20
6.6 Financial information and statistics ............................................................................................... 21
6.7 Quality improvement, risk management and regulatory agencies ............................................... 21
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6.8 Clinical speciality committees ....................................................................................................... 22
6.9 Participation in clinical teaching activities ..................................................................................... 22
6.10 Research ....................................................................................................................................... 22
6.11 Obtain written approval for New Clinical Services ........................................................................ 22
6.12 Utilisation ...................................................................................................................................... 23
Part C – Accreditation of Medical Practitioners .............................................. 23
7. Credentialing and Scope of Practice ...................................................... 23
7.1 Eligibility for Accreditation as a Medical Practitioner .................................................................... 23
7.2 Entitlement to treat Patients at the Facility ................................................................................... 23
7.3 Responsibility and basis for Accreditation and granting of Scope of Practice ............................. 23
7.4 Principles of Credentialing and Accreditation ............................................................................... 24
7.5 Medical Advisory and Audit Committee ........................................................................................ 24
8. The process for appointment and re-appointment................................ 25
8.1 Applications for Initial Accreditation and Re-Accreditation as Medical Practitioners ................... 25
8.2 Consideration by the Medical Advisory and Audit Committee ...................................................... 25
8.3 Consideration of applications for Initial Accreditation by the Board ............................................. 26
8.4 Initial Accreditation tenure ............................................................................................................ 27
8.5 Re-Accreditation ........................................................................................................................... 28
8.6 Re-Accreditation tenure ................................................................................................................ 29
8.7 Nature of appointment .................................................................................................................. 29
9. Temporary and Emergency Accreditation ............................................. 29
9.1 Temporary Accreditation ............................................................................................................... 29
9.2 Emergency Accreditation .............................................................................................................. 30
9.3 Locum Tenens .............................................................................................................................. 30
10. Variation of Accreditation or Scope of Practice .................................... 31
10.1 Practitioner may request amendment of Accreditation or Scope of Practice ............................... 31
11. Review of Accreditation or Scope of Practice ....................................... 31
11.1 Initiation of Review of Accreditation or Scope of Practice ............................................................ 31
11.2 Internal Review of Accreditation and Scope of Practice ............................................................... 32
11.3 External Review of Accreditation and scope of practice .............................................................. 33
12. Suspension, termination, imposition of conditions, resignation and expiry of Accreditation ............................................................................ 34
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12.1 Suspension of Accreditation ......................................................................................................... 34
12.2 Termination of Accreditation ......................................................................................................... 37
12.3 Imposition of conditions ................................................................................................................ 39
12.4 Resignation and expiry of Accreditation ....................................................................................... 40
13. Appeal rights and procedure .................................................................. 40
13.1 Rights of appeal against decisions affecting Accreditation .......................................................... 40
13.2 Appeal process ............................................................................................................................. 41
Part D – Accreditation of Dentists ................................................................... 42
14. Accreditation and Scope of Practice of Dentists .................................. 43
Part E – Accreditation of Visiting Allied Health Professionals ...................... 43
15. Accreditation and Scope of Practice of Visiting Allied Health Professionals ............................................................................................ 43
Part F – Amending By-laws, annexures, and associated policies and procedures, and other matters ............................................................... 43
16. Amendments to, and instruments created pursuant to, the By-laws .. 43
17. Audit and Compliance ............................................................................. 44
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1. Preface
Presmed Australia, established in 1997, specialises in the investment, commissioning and management of day hospital facilities in partnership with surgeons.
2. Mission, Vision, Values and Objectives
PresMed Australia Mission
PresMed Australia is totally committed to providing uncompromising quality in patient care, professional service in support of our medical practitioners and the cost-effective utilisation of all resources through the self-actualisation of all our personnel.
PresMed Facility Mission
In partnership with our patients, staff and customers we will provide a quality healthcare
service.
PresMed Australia Vision
To be an innovative leader in the development of dedicated surgery facilities by providing
the highest standards of professional services and to deliver these cost effectively.
PresMed Facility Vision
To provide excellence in healthcare through the dedication of a committed, competent and
compassionate team who meet and exceed our patient needs through an outcome based
healthcare service.
PresMed Australia Values
The PresMed Australia Group and its employees stand for the following core values:
Integrity and high ethical values will form the basis of all of our dealings with patients,
doctors, clients, business partners, government authorities, the public and our own
employees;
All our employees acknowledge their responsibility towards patients, medical
practitioners and fellow employees, and their conduct towards such persons will be
conducive to growth, dignity and respect;
The company expects all employees to perform their duties conscientiously, honestly
and in the best interest of our patients and PresMed Australia;
No employee may receive commission or other remuneration related to the sale of any
product of the company, except as specifically provided under an individual’s terms of
employment;
Employees may not receive any monies or items of value (other than the company’s
regular remuneration or other incentives), either directly or indirectly for negotiation,
procuring, recommending or aiding in any transaction made by or on behalf of the
company, nor have any direct or indirect financial interest in such a transaction;
All employees undertake to protect the confidentiality of patient and company matters
at all times;
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Information gained during the performance of duties is confidential, even after an
employee has left the employ of the company, and may not be discussed with any
other person who is not directly involved in the matter;
No personal favour or other preferential treatment should be accepted by any
employee when it is offered and which might therefore place the recipient under
obligation.
PresMed Australia Objectives
EFFICIENCY AND PRODUCTIVITY
To provide all necessary plant and equipment and facilities, assistance and
management to staff and visiting medical practitioners to enable them to maintain
the provision of the highest standards of patient care.
SAFETY AND SECURITY
To ensure an effective companywide risk management plan and risk management
strategies that ensure a safe and secure environment for our customers. To
implement, maintain and continually review our L&M 3.1 “Quality and Risk
Management Framework” so that we can monitor and benchmark our performance
between PMA facilities and within the industry.
CUSTOMER SATISFACTION
To ensure our high quality service is delivered in a personal, compassionate,
convenient and cost-effective manner. To maintain excellence in all services
offered by all PMA facilities through participation, evaluation and feedback from our
patients, staff and doctors.
STAFF DEVELOPMENT AND RELATIONSHIPS
To provide and maintain a highly professional atmosphere that formulates,
evaluates and implements policies and procedures in accordance with recognised
professional and ethical standards. To ensure the value of each team member is
recognised.
FINANCIAL PERFORMANCE
To monitor and maintain a high level of financial performance through corporate
governance and monitoring of key performance indicators.
The mission, vision, values and objectives, where applicable, should be used to guide the application of the By-laws.
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Part A – Definitions and introduction
3. Definitions and interpretation
3.1 Definitions
In these By-laws, unless indicated to the contrary or the context otherwise requires:
Accreditation means the process provided for in these By-laws by which a person is
Accredited.
Accreditation Category means as part of Accreditation, the appointment of an Accredited
Practitioner to one of more of the following categories: Career Medical Officer, Consultant
Emeritus, Dentist, Fellow Medical Practitioner, General Medical Practitioner, Medical
Practitioner, Specialist Medical Practitioner, Registrar, Staff Specialist, Surgical Assistant –
Medical Practitioner and Surgical Assistant – Non Medical Practitioner. The Board may from
time to time approve other Accreditation Categories.
Accreditation Type means as part of Accreditation, the appointment of an Accredited
Practitioner with one or more of the following: admitting privileges, anaesthetic privileges,
consulting privileges, diagnostic privileges, procedural privileges, surgical assist privileges –
medical practitioner, surgical assist privileges – registered nurse, and surgical privileges.
The Board may from time to time approve other Accreditation Types.
Accredited means the status conferred on a Medical Practitioner, Dentist or other
practitioner authorising them to provide services within the Facility after having satisfied the
Credentialing requirements provided in these By-laws, with the authorisation being to
deliver medical, surgical, dental or other services to Patients at the Facility in accordance
with the Accreditation Category, Accreditation Type, Scope of Practice, any specified
conditions, the policies and procedures in place at the Facility and these By-laws.
Accredited Practitioner means a Medical Practitioner, Dentist or other practitioner who
has been Accredited to provide services within the Facility, including an Accredited
Medical Practitioner and Accredited Dentist, with Accreditation to perform services at the
Facility within the Accreditation Category, Accreditation Type and Scope of Practice notified
in the appointment.
Adequate Professional Indemnity Insurance means insurance, including run off/tail
insurance, to cover all potential liability of the Accredited Practitioner, that is with a
reputable insurance company acceptable to the Board, and is in an amount and on terms
that the Board considers in its absolute discretion to be sufficient. The insurance must be
adequate for Scope of Practice and level of activity.
AHPRA means the Australian Health Practitioner Regulation Agency established under the
Health Practitioner Regulation National Law Act 2009 (as in force in each State and
Territory)
Behavioural Sentinel Event means an episode of inappropriate or problematic behaviour
which indicates concerns about an Accredited Practitioner’s level of functioning and
suggests potential for adversely affecting Patient safety or Facility outcomes.
Behavioural Standards means the standard of conduct and behaviour expected of an
Accredited Practitioner arising from personal interactions, communication and other forms
of interaction with other Accredited Practitioners, employees of the Facility, Board members,
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executive of the Facility and PresMed Australia, third party service providers, Patients,
family members of Patients and others. The minimum standard required of Accredited
Practitioners in order to achieve the Behavioural Standards is compliance with the Code of
Conduct, the expectations set out in the Good Medical Practice: A Code of Conduct for
Doctors in Australia (as applicable), the mission, vision, values and objectives set out in By-
law 2.
Board means the Board of Directors of the Facility.
By-laws means these By-laws.
Chief Executive Officer or CEO means the person appointed to the position of CEO of
PresMed Australia, or any person acting, or delegated to act, in that position.
Clinical Practice means the professional activity undertaken by Accredited Practitioners for
the purposes of investigating Patient symptoms and preventing and/or managing illness,
together with associated professional activities related to clinical care.
Code of Conduct means the relevant code of conduct of PresMed Australia and/or the
Facility.
Competence means, in respect of a person who applies for Accreditation or Re-
Accreditation, that the person is possessed of the necessary knowledge, skills, training,
decision-making ability, judgement, insight, interpersonal communication and Performance
necessary for the Scope of Practice for which the person has applied and has the
demonstrated ability to provide health services at an expected level of safety and quality.
Credentials means, in respect of a person who applies for Accreditation or Re-
Accreditation, the identity, education, formal qualifications, equivalency of overseas
qualifications, post-graduate degrees/awards/fellowships/certificates, professional training,
continuing professional development, professional experience, recency of practice,
maintenance of clinical competence, current registration and status, indemnity insurance,
and other skills/attributes (for example training and experience in leadership, research,
education, communication and teamwork) that contribute to the Competence, Performance,
Current Fitness and professional suitability to provide safe, high quality health care services
at the Facility. This may include (where applicable and relevant) history of and current
status with respect to Clinical Practice and outcomes during period previous of
Accreditation, disciplinary actions, By-law actions, compensation claims, complaints and
concerns – clinical and behavioural, professional registration and professional indemnity
insurance.
Credentialing means, in respect of a person who applies for Accreditation or Re-
Accreditation, the formal process used to match the skills, experience and qualifications to
the role and responsibilities of the position. This will include actions to verify and assess the
identity, education, formal qualifications, equivalency of overseas qualifications, post-
graduate degrees/awards/fellowships/certificates, professional training, continuing
professional development, professional experience, recency of practice, maintenance of
clinical competence, current registration and status, indemnity insurance, and other
skills/attributes (for example training and experience in leadership, research, education,
communication and teamwork) for the purpose of forming a view about their Credentials,
Competence, Performance, Current Fitness and professional suitability to provide safe, high
quality health care services within specific Facility environments. Credentialing involves
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obtaining evidence contained in verified documents to delineate the theoretical range of
services which an Accredited Practitioner is competent to perform.
Current Fitness is the current fitness required of an applicant for Accreditation or Re-Accreditation to carry out the Scope of Practice sought or currently held, including with the confidence of peers and the Board, having regard to any relevant physical or mental impairment, disability, condition or disorder (including due to alcohol, drugs or other substances) which detrimentally affects or there is a reasonably held concern that it may detrimentally affect the person's capacity to provide health services at the expected level of safety and quality having regard to the Scope of Practice sought or currently held.
Dentist means a person registered as a dentist by the Dental Board of Australia governed
by the AHPRA pursuant to the Health Practitioner Regulation National Law Act 2009 as in
force in each State and Territory.
Director of Nursing means the person appointed to the position of Director of Nursing or
Director of Clinical Services, or equivalent position by whatever name, of the Facility or any
person acting, or delegated to act, in that position.
Disruptive Behaviour means aberrant behaviour manifested through personal interaction
with Medical Practitioners, hospital personnel, health care professionals, Patients, family
members, or others, which interferes with Patient care or could reasonably be expected to
interfere with the process of delivering quality care or which is inconsistent with the values
of the Facility.
Emergency Accreditation means the process provided in these By-laws whereby a
Medical Practitioner, Dentist or other practitioner is Accredited for a specified short period
on short notice in an emergency situation.
External Review means evaluation of the performance of an Accredited Practitioner by an
appropriately qualified and experienced professional person(s) external to the Facility.
Facility means the Presmed Australia hospital or facility to which an application for
Accreditation is made.
Facility Manager means the person appointed to the position of Facility Manager, or
equivalent position by whatever name, of the Facility or any person acting, or delegated to
act, in that position.
Internal Review means evaluation of the performance of an Accredited Practitioner by an
appropriately qualified and experienced professional person(s) internal to PresMed
Australia or the Facility.
Medical Advisory and Audit Committee (MAAC) means the medical advisory and audit
committee of the Facility.
Medical Practitioner means a person registered as a medical practitioner by the Medical
Board of Australia governed by the AHPRA pursuant to the Health Practitioner Regulation
National Law Act 2009 as in force in each State and Territory.
New Clinical Services means clinical services, treatment, procedures, techniques,
technology, instruments or other interventions that are being introduced into the
organisational setting of the Facility for the first time, or if currently used are planned to be
used in a different way, and that depend for some or all of their provision on the
professional input of Medical Practitioners.
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Organisational Capability means the Facility’s ability to provide the facilities, services,
clinical and non-clinical support necessary for the provision of safe, high quality clinical
services, procedures or other interventions. Organisational Capability will be determined by
consideration of, but not limited to, the availability, limitations and/or restrictions of the
services, staffing (including qualifications and skill-mix), facilities, equipment, technology
and support serves required and by reference to the Facility's private health licence (where
applicable), clinical service capacity, Approved Procedures policy and Patient Selection
Protocol .
Organisational Need means the extent to which the Facility considers it necessary to
provide a specific clinical service, procedure or other intervention, or elects to provide
additional resources to support expansion of an existing clinical service, procedure or other
intervention (including additional operating theatre utilisation), in order to provide a balanced
mix of safe, high quality health care services that meet the Facility, consumer and
community needs and aspirations. Organisational Need will be determined by, but not
limited to, allocation of limited resources, clinical service capacity, funding, clinical services,
strategic, business and operational plans, and the facility’s Approved Procedures policy and
Patient Selection Protocol.
Patient means a person admitted to, or treated as a patient at, the Facility.
Performance means the extent to which an Accredited Practitioner provides, or has
provided, health care services in a manner which is considered consistent with good and
current Clinical Practice and results in expected patient benefits and outcomes. When
considered as part of the Accreditation process, Performance will include an assessment
and examination of the provision of health care services over the prior periods of
Accreditation (if any).
PresMed Australia or PMA means the management company and main shareholder of
each Facility.
Re-accreditation means the process provided in these By-laws by which a person who
already holds Accreditation may apply for and be considered for Accreditation following the
probationary period or any subsequent term.
Scope of Practice means the extent of an individual Accredited Practitioner’s permitted
Clinical Practice within the Facility based on the individual’s Credentials, Competence,
Performance and professional suitability, and the Organisational Capability and
Organisational Need of the organisation to support the Accredited Practitioner’s scope of
clinical practice. Scope of Practice may also be referred to as delineation of clinical
privileges.
Specialist Medical Practitioner means a Medical Practitioner who has been recognised as
a specialist in their nominated category for the purpose of the Health Insurance Act 1973
(Cth).
Temporary Accreditation means the process provided in By-laws whereby a Medical
Practitioner, Dentist or other practitioner is Accredited for a limited period.
Threshold Credentials means the minimum credentials for each clinical service, procedure
or other intervention which applicants for Credentialing, within the Scope of Practice sought,
are required to meet before any application will be processed and approved. Threshold
credentials are to be approved by the Board and may be incorporated into an Accreditation
policy.
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Visiting Dentist means a Dentist who is not an employee of the Facility, who has been
granted Accreditation and Scope of Practice pursuant to these By-laws.
Visiting Medical Practitioner means a Medical Practitioner who is not an employee of the
Facility, who has been granted Accreditation and Scope of Practice pursuant to these By-
laws. Visiting Medical Practitioners include visiting Specialist Medical Practitioners.
3.2 Interpretation
Headings in these By-laws are for convenience only and are not to be used as an aid in interpretation.
In these By-laws, unless the context makes it clear the rule of interpretation is not intended to apply, words importing the masculine gender shall also include feminine gender, words importing the singular shall also include the plural, if a word is defined another part of speech has a corresponding meaning, if an example is given the example does not limit the scope, and reference to legislation (including subordinate legislation or regulation) is to that legislation as amended, re-enacted or replaced.
The CEO and Facility Manager may delegate any of the responsibilities conferred upon him/her by the By-laws in his/her complete discretion, but within any approved delegation parameters.
Any dispute or difference which may arise as to the meaning or interpretation or application of these By-laws or as to the powers of any committee or the validity of proceedings of any meeting shall be determined by the Board. There is no appeal from such a determination by the Board.
3.3 Meetings
Where a reference is made to a meeting, the quorum requirements that will apply are those specified in the terms of reference of the relevant committee. If there are no terms of reference, where there is an odd number of members a quorum will be a majority of the members, or where there is an even number of members a quorum will be half of the number of the members plus one.
Committee resolutions and decisions, if not specified in the terms of reference, must be supported by a show of hands or ballot of committee members at the meeting.
Voting, if not specified elsewhere, shall be on a simple majority voting basis and only by those in attendance at the meeting (including attendance by electronic means). There shall be no proxy vote.
In the case of an equality of votes, the chairperson will have the casting vote.
A committee established pursuant to these By-laws may hold any meeting by electronic means or by telephonic communication whereby participants can heard.
Resolutions may be adopted by means of a circular resolution.
Information provided to any committee or person shall be regarded as confidential and is not to be disclosed beyond the purpose for which the information was made available, subject to the exceptions set out in these By-laws.
Any member of a committee who has a conflict of interest or material personal interest in a matter to be decided or discussed shall inform the chairperson of the committee and subject to any agreed resolution on the matter shall take no part in any relevant discussion or resolution with respect to that particular matter. This will include a member of the MAAC whose application for Accreditation is being considered.
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4. Introduction
4.1 Purpose of this document
(a) The By-laws provide direction in relation to exercise of certain aspects of managerial
responsibility.
(b) Patient care is provided by Accredited Practitioners who have been granted access
to use the Facility in order to provide that care. The By-laws define the relationship
and obligations between the Facility and its Accredited Practitioners.
(c) This document sets out certain terms and conditions upon which Medical
Practitioners, Dentists and other practitioners may apply to be Accredited within the
defined Scope of Practice granted, the basis upon which a successful applicant may
admit Patients and/or care and treat Patients at the Facility, and the terms and
conditions for continued Accreditation.
(d) Every applicant for Accreditation will be given a copy of this document and
Annexures before or at the time of making an application. It is expected that the By-
laws are read in their entirety by the applicant as part of the application process.
(e) The Facility aims to maintain a high standard of Patient care and to continuously
improve the safety and quality of its services. The By-laws implement measures
aimed at maintenance and improvements in safety and quality.
(f) Health care in Australia is subject to numerous legislation and standards. The By-
laws assist in compliance with certain aspects of this regulation but are not a
substitute for review of the relevant legislation and standards.
Part B – Terms and conditions of Accreditation
5. Compliance with By-laws
5.1 Compliance obligations
(a) It is a requirement for continued Accreditation that Accredited Practitioners comply
with the By-laws at all relevant times when admitting, caring for or treating Patients,
or otherwise providing services at the Facility.
(b) Any non-compliance with the By-laws may be grounds for suspension, termination,
or imposition of conditions.
(c) Unless specifically determined otherwise by the Board in writing for a specified
Accredited Practitioner, the provisions of these By-laws in their entirety prevail to the
extent of any inconsistency with any terms, express or implied, in a contract of
employment or engagement that may be entered into. In the absence of a specific
written determination by the Board, it is a condition of ongoing Accreditation that the
Accredited Practitioner agrees that the provisions of these By-laws prevail to the
extent of any inconsistency or uncertainty between the provisions of these By-laws
and any terms, express or implied, in a contract or employment or engagement.
5.2 Compliance with policies and procedures
Accredited Practitioners must comply with all policies and procedures of PresMed Australia and the Facility.
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5.3 Compliance with legislation
Accredited Practitioners must comply with all relevant legislation, including but not limited to legislation that relates to health, public health, drugs and poisons, privacy, coroners, criminal law, health practitioner registration, research, environmental protection, workplace health & safety, occupational health and safety, antidiscrimination, bullying, harassment, industrial relations, care of children, care of persons with a disability, substituted decision making and persons with impaired capacity, mental health, Medicare, health insurance, competition and consumer law, intellectual property, and other relevant legislation regulating the Accredited Practitioner, provision of health care or impacting upon the operation of the Facility.
In addition, Accredited Practitioners must ensure compliance with, or assist the Facility to comply with, any Commonwealth or State mandated service capability frameworks or minimum standards.
5.4 Insurance and registration
Accredited Practitioners must at all times maintain Adequate Professional Indemnity Insurance.
Accredited Practitioners must at all times maintain registration with AHPRA that is sufficient for the Scope of Practice granted.
Accredited Practitioners are required to provide evidence annually, or at other times upon request, of Adequate Professional Indemnity Insurance and registration, and all other relevant licences or registration requirements for the Scope of Practice granted. If further information is requested in relation to insurance or registration, the Accredited Practitioner will assist to obtain that information, or provide permission for the Facility to obtain that information directly.
5.5 Standard of conduct and behaviour
(a) The Facility expects a high standard of professional and personal conduct from
Accredited Practitioners, who must conduct themselves at all times in accordance
with:
(i) the Behavioural Standards;
(ii) the Code of Ethics of the Australian Medical Association or any other relevant
code of ethics;
(iii) the Code of Practice of any specialist college or professional body of which
the Accredited Practitioner is a member;
(iv) the Values of the Facility;
(v) the limits of their registration or any conditions placed upon Scope of Practice
in accordance with these By-laws; and
(vi) all requests made with regard to personal conduct in the Facility.
(b) Accredited Practitioners must continuously demonstrate Competence and Current
Fitness, must not engage in Disruptive Behaviour, and must observe all reasonable
requests with respect to conduct and behaviour.
(c) Accredited Practitioners must not engage in any conduct that may be perceived as a
reprisal against another person for making a report or supplying information relating
to the Behavioural Standards.
(d) Upon request by the CEO or Facility Manager, the Accredited Practitioner is required
to meet with the CEO and/or Facility Manager and any other person that the CEO
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and/or Facility Manager may ask to attend the meeting, to discuss matters in a) to c)
above, or any other matter arising out of these By-Laws.
5.6 Notifications
Accredited Practitioners must immediately advise the CEO or Facility Manager, and follow up with written confirmation within 2 days, should:
(a) an investigation or complaint be commenced in relation to the Accredited
Practitioner, or about his/her Patient (irrespective of whether this relates to a Patient
of the Facility), by AHPRA, the Accredited Practitioner's registration board,
disciplinary body, Coroner, a health complaints body, or another statutory authority,
State or Government agency;
(b) an adverse finding (including but not limited to criticism or adverse comment about
the care or services provided by the Accredited Practitioner) be made against the
Accredited Practitioner by a civil court, AHPRA, the practitioner's registration board,
disciplinary body, Coroner, a health complaints body, or another statutory authority,
State or Government agency, irrespective of whether this relates to a Patient of the
Facility;
(c) the Accredited Practitioner's professional registration be revoked or amended, or
should conditions be imposed, or should undertakings be agreed, irrespective of
whether this relates to a Patient of the Facility and irrespective of whether this is
noted on the public register or is privately agreed with a registration board;
(d) professional indemnity membership or insurance be made conditional or not be
renewed, or should limitations be placed on insurance or professional indemnity
coverage;
(e) the Accredited Practitioner's appointment, clinical privileges or Scope of Practice at
any other facility, hospital or day procedure centre alter in any way, including if it is
withdrawn, suspended, restricted, or made conditional, and irrespective of whether
this was done by way of agreement;
(f) any physical or mental condition or substance abuse problem occur that could affect
his or her ability to practise or that would require any special assistance to enable
him or her to practise safely and competently;
(g) the Accredited Practitioner be charged with having committed or is convicted of a
sex, violence or other criminal offence. The Accredited Practitioner must provide an
authority to conduct at any time a criminal history check with the appropriate
authorities;
(h) the Accredited Practitioner believe that Patient care or safety is being compromised
or at risk, or may potentially be compromised or at risk, by another Accredited
Practitioner of the Facility; or
(i) the Accredited Practitioner make a mandatory notification to a health practitioner
registration board in relation to another Accredited Practitioner of the Facility.
In addition, Accredited Practitioners should inform themselves of their personal obligations
in relation to external notifications and ensure compliance with these obligations, including
for example as a member of a Medical Advisory Committee in New South Wales pursuant
to the Private Health Facilities Act (NSW) or mandatory reporting to AHPRA. The Facility
expects the Accredited Practitioner to comply with these obligations.
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5.7 Continuous disclosure
(a) The Accredited Practitioner must keep the CEO or Facility Manager continuously
informed of every fact and circumstances which has, or will likely have, a material
bearing upon:
(i) the Accreditation of the Accredited Practitioner;
(ii) the Scope of Practice of the Accredited Practitioner;
(iii) the ability of the Accredited Practitioner to safely deliver health services to
his/her Patients within the Scope of Practice, including if the Accredited
Practitioner suffers from an illness or disability which may adversely affect his
or her Current Fitness;
(iv) the Accredited Practitioner's registration or professional indemnity insurance
arrangements;
(v) the inability of the Accredited Practitioner to satisfy a medical malpractice
claim by a Patient;
(vi) adverse outcomes, complications, complaints, claims, reportable deaths and
coronial investigations in relation to the Accredited Practitioner's Patients
(current or former) of the Facility;
(vii) the reputation of the Accredited Practitioner as it relates to the provision of
Clinical Practice; and
(viii) the reputation of the Facility.
(b) Subject to restrictions directly relating to or impacting upon legal professional
privilege or statutory obligations of confidentiality, every Accredited Practitioner must
keep the CEO or Facility Manager informed and updated about the commencement,
progress and outcome of compensation claims, coronial investigations or inquests,
police investigations, Patient complaints, health complaints body complaints or
investigations, or other inquiries involving Patients of the Accredited Practitioner that
were treated at the Facility.
5.8 Representations and media
Unless an Accredited Practitioner has the prior written consent of the Facility Manager, an Accredited Practitioner may not use PresMed Australia or the Facility's (which for the purposes of this provision includes a corporate or business name, its parent companies or subsidiary companies) name, letterhead, or in any way suggest that the Accredited Practitioner represents these entities.
The Accredited Practitioner must obtain the CEO or Board's prior approval before interaction with the media regarding any matter involving the Facility or a Patient.
5.9 Committees
(a) Accredited Practitioners will, as reasonably requested by the Board, assist in
achieving the Facility's goals and strategic direction, and provision of high level care
and services, through membership of committees of the Facility. This includes
committees responsible for developing, implementing and reviewing policies in all
clinical areas; participating in medical, nursing and other education programs; and
attending meetings of Medical Practitioners and Dentists.
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5.10 Confidentiality
(a) Accredited Practitioners will manage all matters relating to the confidentiality of
information in compliance with the policy in place at the Facility, the 'Australian
Privacy Principles' established by the Privacy Act (Cth), and other legislation and
regulations relating to privacy and confidentiality, and will not do anything to bring the
Facility in breach of these obligations.
(b) Accredited Practitioners will comply with the various legislation governing the
collection, handling, security, storage and disclosure of health information, as well as
notification of data breaches.
(c) Accredited Practitioners will comply with common law duties of confidentiality.
(d) The following will also be kept confidential by Accredited Practitioners:
(i) Commercial in confidence business information concerning PresMed
Australia and the Facility;
(ii) The particulars of these By-Laws;
(iii) Information concerning the Facility's insurance arrangements;
(iv) information concerning any Patient or staff of PresMed Australia or the
Facility;
(v) information which comes to their knowledge concerning Patients, Clinical
Practice, quality assurance, peer review and other activities which relate to
the assessment and evaluation of clinical services.
(e) In addition to statutory or common law exceptions to confidentiality, the
confidentiality requirements do not apply in the following circumstances:
(i) where disclosure is required to provide continuing care to the Patient;
(ii) where disclosure is required by law;
(iii) where disclosure is made to a regulatory or registration body in connection
with the Accredited Practitioner, another Accredited Practitioner, or the
Facility;
(iv) where the person benefiting from the confidentiality consents to the disclosure
or waives the confidentiality; or
(v) where disclosure is required in order to perform some requirement of these
By-Laws.
(f) The confidentiality requirements continue with full force and effect after the
Accredited Practitioner ceases to be Accredited.
5.11 Communication
Accredited Practitioners are required to familiarise themselves with the organisational structure of PresMed Australia and the Facility.
Accredited Practitioners acknowledge that in order for the organisation to function, effective communication is required, including between the CEO, Board, Facility Manager, Director of Nursing, Committees of the Facility, staff of the Facility, other Accredited Practitioners and entities/representatives of PresMed Australia.
Accredited Practitioners acknowledge and consent to communication between these persons and entities of information, including their own personal information, that may otherwise be restricted by the Privacy Act. The acknowledgment and consent is given on
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the proviso that the information will be dealt with in accordance with obligations pursuant to the Privacy Act and only for proper purposes and functions.
6. Safety and quality
6.1 Admission, availability, communication, & discharge
(a) All Accredited Practitioners shall admit or treat Patients at the Facility on a regular
basis and be an active provider of services at the Facility.
(b) Accredited Practitioners will admit and treat Patients only within the Accreditation
Category, Accreditation Type and Scope of Practice granted, including any terms or
conditions attached to the approval of Accreditation.
(c) Accredited Practitioners will not provide services or practice outside of the defined
service capability of the Facility.
(d) Accredited Practitioners who admit Patients to the Facility for treatment and care
accept that they are at all times responsible for the care of their Patient and must
ensure that they are available to treat and care for those Patients at all times, or
failing that, that other arrangements as permitted by the By-laws are put in place to
ensure the continuity of treatment and care for those Patients.
(e) Accredited Practitioners must visit all Patients admitted or required to be treated by
them as frequently as is required by the clinical circumstances of those Patients and
as would be judged appropriate by professional peers. An Accredited Practitioner will
be contactable to review the Patient in person or their on-call or locum cover is
available as requested by nursing staff to review the Patient in the Facility.
Accredited Practitioners must ensure that all reasonable requests by Facility staff are
responded to in a timely manner and in particular Patients are promptly attended to
when reasonably requested by Facility staff for clinical reasons. If Accredited
Practitioners are unable to provide this level of care personally, he/she shall secure
the agreement of another Accredited Practitioner to provide the care and treatment,
and shall advise the staff of the Facility of this arrangement.
(f) Accredited Practitioners must be available and attend upon Patients of the
Accredited Practitioner in a timely manner when requested by Facility staff or be
available by telephone in a timely manner to assist Facility staff in relation to the
Accredited Practitioner's Patients. Alternatively, the Accredited Practitioner will make
arrangements with another Accredited Practitioner to assist or will put in place with
prior notice appropriate arrangements in order for another Accredited Practitioner to
assist, and shall advise the staff of the Facility of this arrangement.
(g) It is the responsibility of the Accredited Practitioner to ensure any changes to contact
details are notified promptly to the Facility Manager. Accredited Practitioners must
ensure that their communication devices are functional and that appropriate
alternative arrangements are in place to contact them if their communication devices
need to be turned off for any reason.
(h) A locum must be approved in accordance with these By-laws and the Accredited
Practitioner must ensure that the locum's contact details are made available to the
Facility and all relevant persons are aware of the locum cover and the dates of locum
cover.
(i) Accredited Practitioners are required to work with and as part of a multi-disciplinary
health care team, including effective communication – written and verbal, to ensure
the best possible care for Patients. Accredited Practitioners must at all times be
aware of the importance of effective communication with other members of the
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health care team, referring doctors, the Facility executive, Patients and the Patient's
family or next of kin, and at all times ensure appropriate communication has
occurred, adequate information has been provided, and questions or concerns have
been adequately responded to.
(j) The Accredited Practitioner must appropriately supervise the care that is provided by
the Facility staff and other practitioners. This includes providing adequate
instructions to, and supervision of, Facility staff to enable staff to understand what
care the Accredited Practitioner requires to be delivered.
(k) Adequate instructions and clinical handover is required to be given to the Facility
staff and other practitioners (including their on-call and locum cover) to enable them
to understand what care the Accredited Practitioner requires to be delivered.
(l) If care is transferred to another Accredited Practitioner, this must be noted on the
Patient medical record and communicated to the Facility Manager or other
responsible nursing staff member.
(m) Accredited Practitioners must give consideration to their own potential fatigue and
that of other staff involved in the provision of patient care, when making patient
bookings and in utilising operating theatre and procedural Facility time.
(n) Accredited Practitioners must participate in formal on call arrangements as
reasonably required by the Facility. Persons providing on-call or cover services must
be Accredited at the Facility.
(o) The Accredited Practitioner must ensure that their Patients are not discharged
without the approval of the Accredited Practitioner, complying with the discharge
policy of the Facility and completing all Patient discharge documents required by the
Facility. It is the responsibility of the Accredited Practitioner to ensure all information
reasonably necessary to ensure continuity of care after discharge is provided to the
referring practitioner, general practitioner and/or other treating practitioner.
6.2 Surgery
Accredited Practitioners must effectively utilise allocated theatre sessions that have been
requested by the Accredited Practitioner.
Accredited Practitioners may only utilise as surgical assistants practitioners Accredited in
accordance with these By-Laws.
Accredited Practitioners acknowledge the importance of, and will strictly adhere to, various
measures aimed at ensuring safety and quality during surgery, which includes but is not
limited to participating in or allowing to occur procedures relating to correct site surgery,
team time out, infection control and surgical item counts.
6.3 Facility, State Based and National Safety Programs, Initiatives and Standards
Accredited Practitioners acknowledge the importance of ongoing safety and quality
initiatives that may be instituted by the Facility based upon its own safety and quality
program, or safety and quality initiatives, programs or standards of State or Commonwealth
health departments, statutory bodies or safety and quality organisations (including for
example the national Australian Commission on Safety and Quality in Health Care, a State
based division of a Health Department or a State based independent statutory body).
Accredited Practitioners will participate in and ensure compliance with these initiatives and
programs (including if they are voluntary initiatives that the Facility elects to participate in or
undertake), whether these apply directly to the Accredited Practitioner or are imposed upon
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the Facility and require assistance from the Accredited Practitioner to ensure compliance,
including but not limited to the National Safety and Quality Health Service Standards and
Clinical Care Standards of the Australian Commission on Safety and Quality in Health Care.
Accredited Practitioners must complete the Presmed Australia Clinical Education pack at
application and annually.
6.4 Treatment and financial consent
Accredited Practitioners must obtain fully informed consent for treatment (except where it is not practical in cases of emergency) from the Patient or their legal guardian or substituted decision maker in accordance with accepted medical and legal standards (including applicable legislation) and in accordance with the policy and procedures of the Facility.
For the purposes of this provision, an emergency exists where immediate treatment is necessary in order to save a person's life or to prevent serious injury to a person's health.
The consent will be evidenced in writing and signed by the Accredited Practitioner and Patient or their legal guardian or substituted decision maker.
It is expected that fully informed consent will be obtained by the Accredited Practitioner under whom the Patient is admitted or treated, with this the sole legal responsibility of the Accredited Practitioner. The consent process will ordinarily include an explanation of the Patient's condition and prognosis, treatment and alternatives, inform the Patient of material risks associated with treatment and alternatives, following which consent to the treatment will be obtained.
The consent process must also satisfy the Facility's requirements from time to time as set out in its policy and procedures, including in relation to the documentation to be provided to the Facility.
Accredited Practitioners must provide full financial disclosure and obtain fully informed financial consent from their Patients in accordance with the relevant legislation, health fund agreements, policy and procedures of the Facility.
6.5 Patient Records
Accredited Practitioners must ensure that:
(a) Patient records held by the Facility are adequately maintained for Patients treated by
the Accredited Practitioner;
(b) Patient records satisfy the Facility policy requirements, legislative requirements,
State based standards, the content and standard required by the Australian Council
on Healthcare Standards, accreditation requirements, and health fund obligations;
(c) they maintain full, accurate, legible and contemporaneous medical records, including
in relation to each attendance upon the Patient, with the entries dated, time and
signed;
(d) they comply with all legal requirements and standards in relation to the prescription
and administration of medication, and properly document all drugs orders clearly and
legibly in the medication chart maintained by the Facility;
(e) Patient records maintained by the Facility include all relevant information and
documents reasonably necessary to allow Facility staff and other Accredited
Practitioners to care for Patients, including provision of pathology, radiology and
other investigative reports in a timely manner;
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(f) A procedure report is completed including a detailed account of the findings,
technique undertaken, complications and post procedure orders;
(g) An anaesthetic report is completed, as well as documentation of the pre-anaesthetic
evaluation, fully informed anaesthetic consent and post-anaesthetic evaluation;
(h) A discharge summary is completed that includes all relevant information reasonably
required by the referring practitioner, general practitioner or other treating practitioner
for ongoing care of the Patient.
6.6 Financial information and statistics
(a) Accredited Practitioners must record all data required by the Facility to meet health
fund obligations, collect revenue and allow compilation of health care statistics.
(b) Accredited Practitioners must ensure that all Pharmaceutical Benefits Scheme
prescription requirements and financial certificates are completed in accordance with
Facility policy and regulatory requirements.
6.7 Quality improvement, risk management and regulatory agencies
(a) Accredited Practitioners are required to attend and participate in the Facility's safety,
quality, risk management, education and training activities, including clinical practice
review and peer review activities, and as required by relevant legislation, standards
and guidelines (including those standards and guidelines set by relevant
Commonwealth or State governments, health departments or statutory health
organisations charged with monitoring and investigating safety and quality of health
care). This includes a requirement to meaningfully participate in clinical review and
peer review committee meetings, including review of clinical data and outcomes and
respond to requests for information regarding statistical outliers, adverse events and
cases flagged in incidents, clinical indicator or key performance indicator reporting.
(b) Accredited Practitioners will report to the Facility incidents, complications, adverse
events, deaths and complaints (including in relation to the Accredited Practitioner's
Patients) in accordance with the Facility policy and procedures and where required
by the Facility Manager will assist with incident management, investigation and
reviews (including root cause analysis and other systems reviews), complaints
management, and open disclosure processes.
(c) Accredited Practitioners will participate in risk management activities and programs,
including the implementation by the Facility of risk management strategies and
recommendations from system reviews, and will maintain and comply with the
ongoing minimum competency and continuing professional development
requirements of their professional college with respect to the approved Scope of
Practice.
(d) Accredited Practitioners must provide all reasonable and necessary assistance in
circumstances where the Facility requires assistance from the Accredited
Practitioner in order to comply with or respond to a legal request or direction,
including for example where that direction is pursuant to a court order, or from a
health complaints body, AHPRA, Coroner, Police, State Health Department and its
agencies or departments, State Private Health Regulatory/Licensing Units, and
Commonwealth Government and its agencies or departments.
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6.8 Clinical speciality committees
The Board may establish clinical speciality committees for the purpose of reviewing and advising the Board on performance of the clinical speciality by reference to the Facility’s clinical services, Organisational Capability and Organisational Need. These committees may include but are not limited to peer review and quality activities.
Each clinical speciality committee, in consultation with the Board, will establish terms of reference for the committee and will report annually, or as required by the Board, on its activities to the MAAC, and make recommendations to the MAAC on issues relevant to the clinical speciality.
6.9 Participation in clinical teaching activities
Accredited Practitioners, if requested, are required to reasonably participate in the Facility’s clinical teaching program.
6.10 Research
(a) The Board approves, in principle, the conduct of research (including a clinical trial) in
the Facility. However, no research will be undertaken without the prior approval of
the Board and a Human Research Ethics Committee, following written application by
the Accredited Practitioner.
(b) The activities to be undertaken in the research must fall within the Scope of Practice
of the Accredited Practitioner.
(c) For aspects of the research falling outside an indemnity from a third party (including
the exceptions listed in the indemnity), the Accredited Practitioner must have in place
adequate insurance with a reputable insurer to cover the medical research.
(d) Research will be conducted in accordance with National Health and Medical
Research Council requirements, National Statement on Ethical Conduct in Human
Research 2007 (as amended and updated from time to time), and other applicable
legislation.
(e) An Accredited Practitioner has no power to bind the Facility to a research project
(including a clinical trial) by executing a research agreement.
(f) There is no right of appeal from a decision to reject an application for research.
6.11 Obtain written approval for New Clinical Services
(a) Before treating patients with New Clinical Services, an Accredited Practitioner is
required to obtain the prior written approval of the Board and what is proposed must
fall within the Accredited Practitioner's Scope of Practice or an amendment to the
Scope of Practice has been obtained and must fall within the licensed service
capability of the facility.
(b) The Accredited Practitioner must provide evidence of Adequate Professional
Indemnity Insurance to cover the New Clinical Service, and if requested, evidence
that private health funds will adequately fund the New Clinical Services.
(c) If research is involved, then the By-law dealing with research must be complied with.
(d) The Board’s decision is final and there shall be no right of appeal from denial of
requests for New Clinical Services.
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6.12 Utilisation
Accredited Practitioners may be advised at the time of Accreditation or Re-Accreditation, or
at other times as determined by the Facility Manager, of minimum expectations in relation
to exercising Accreditation and utilisation of the facility. This may include the minimum
number of patient admissions over a specified period of time, the minimum number of
theatre sessions per month or annually, the minimum notice period for cancellation of
theatre sessions and expectations with respect to adherence to start times for
commencement of theatre sessions. Accredited Practitioners must adhere to these
requirements as a condition of Accreditation or Re-Accreditation, subject only to provision
of a reasonable excuse for a particular non-compliance, with acceptance of that reasonable
excuse within the complete discretion of the Facility Manager.
Part C – Accreditation of Medical Practitioners
7. Credentialing and Scope of Practice
7.1 Eligibility for Accreditation as a Medical Practitioner
Accreditation as a Medical Practitioner will only be granted if the Medical Practitioner demonstrates adequate Credentials, is professionally Competent, satisfies the requirements of the By-laws, and is prepared to comply with the By-laws and PresMed Australia / Facility policies and procedures.
By the granting of Accreditation, the Medical Practitioner accepts compliance with the By-laws and PresMed Australia / Facility policies and procedures.
7.2 Entitlement to treat Patients at the Facility
(a) Medical Practitioners who have received Accreditation pursuant to the By-laws are
entitled to make a request for access to facilities for the treatment and care of their
Patients within the limits of the Accreditation Category, Accreditation Type and
Scope of Practice attached to such Accreditation at the Facility and to utilise services
and equipment provided by the Facility for that purpose, subject to the provisions of
the By-laws, Facility policies, resource limitations, and in accordance with
Organisational Need and Organisational Capability.
(b) The decision to grant access to facilities for the treatment and care of a Medical
Practitioner's Patients is on each occasion within the sole discretion of the Board and
Facility Manager and the grant of Accreditation contains no conferral of, or a general
expectation of, or a 'right of access'.
(c) A Medical Practitioner's use of the facilities for the treatment and care of Patients is
limited to the Scope of Practice granted and subject to the conditions upon which the
Scope of Practice is granted, resource limitations, and Organisational Need and
Organisational Capability. Accredited Practitioners acknowledge that admission or
treatment of a particular Patient is subject always to bed availability, the availability
or adequacy of nursing or allied health staff or facilities given the treatment or clinical
care proposed.
7.3 Responsibility and basis for Accreditation and granting of Scope of Practice
The Board will determine the outcome of applications for Accreditation as Medical Practitioners and defined Scope of Practice for each applicant. In making any determination, the Board will make independent and informed decisions and in so doing will have regard to the matters set out in these By-laws and will have regard to the
24
recommendations of the MAAC. The Board may, at its discretion, consider other matters as relevant to the application when making its determination.
7.4 Principles of Credentialing and Accreditation
The following principles should be considered and guide those persons involved in making decisions in the Credentialing and Accreditation process:
(a) Credentialing and Accreditation are organisational governance responsibilities that
are conducted with the primary objective of maintaining and improving the safety and
quality of health care services.
(b) Processes of Credentialing and Accreditation are complemented by registration
requirements and individual professional responsibilities that protect the community.
(c) Effective processes of Credentialing and Accreditation benefit patients, communities,
health care organisations and health care professionals.
(d) Credentialing and Accreditation are essential components of a broader system of
organisational management of relationships with health care professionals.
(e) Credentialing and Accreditation and any reviews should be a non-punitive process,
with the objective of maintaining and improving the safety and quality of health care
services.
(f) Processes for Credentialing and Accreditation depend for their effectiveness on
strong partnerships between health care organisations and professional colleges,
associations and societies.
(g) Processes of Credentialing and Accreditation should be fair and transparent,
although recognising the ultimate ability of the Board to make decisions that they
consider to be in the best interests of the organisation, its current and future patients.
7.5 Medical Advisory and Audit Committee
The Board shall convene a MAAC and it will function in accordance with the terms of
reference established for the MAAC and pursuant to any requirements set out in these By-
laws.
The MAAC members will be a majority of Accredited Practitioners, including the
chairperson.
The MAAC members who are Accredited Practitioners will be appointed by the Board for
such period as determined by the Board and may be removed from membership of the
committee by the Board.
The CEO, Facility Manager and Director of Nursing will also be members of the MAAC.
The Board may establish a Credentialing Committee, which will be a sub-committee of the
MAAC. The Credentialing Committee will function in accordance with the terms of reference
established for that committee. The primary role of a Credentialing Committee will be to
conduct some aspects of the Credentialing requirements set out in these By-laws and make
recommendations to the MAAC. In the event a Credentialing Committee is established, the
responsibilities set out in these By-laws in relation to Credentialing will still ultimately remain
with the MAAC.
In the absence of a Credentialing Committee, the role will be performed by the MAAC. If the
jurisdiction in which the Facility is located requires a separate Credentialing Committee to
25
consider and make recommendations relating to Credentialing, but the role is performed by
the MAAC, the terms of reference for the Credentialing Committee will include a process
that provides for closing the MAAC meeting and reconvening it as a Credentialing
Committee meeting, including recording of separate minutes.
In addition to the terms of reference established for the MAAC or Credentialing Committee,
the Committees must be constituted according to and the members of the Committees must
conduct themselves in accordance with any legislative obligations, including standards that
have mandatory application to the Facility and Committee members. For example, the
obligations imposed pursuant to the Private Health Facilities Act (NSW).
In making determinations about applications for Accreditation there will ordinarily be at least
one member of the same speciality as the applicant on the MAAC, which may mean co-
opting a committee member in order to assist with the determination. It is, however,
recognised that this may not always be possible or practicable in the circumstances, and a
failure to do so will not invalidate the recommendation of the MAAC.
8. The process for appointment and re-appointment
8.1 Applications for Initial Accreditation and Re-Accreditation as Medical Practitioners
(a) Applications for Initial Accreditation (where the applicant does not currently hold
Accreditation at the Facility) and Re-Accreditation (where the applicant currently
holds Accreditation at the Facility) as Medical Practitioners must be made in writing
on the prescribed form. All questions on the prescribed form must be fully completed
and all required information and documents supplied before an application will be
considered. Applications should be forwarded to the CEO at least six weeks prior to
the Medical Practitioner seeking to commence at the Facility or at least three months
prior to expiration of the current Accreditation. Where this timeframe is unable to be
achieved due to Organisational Need or patient needs, Temporary Accreditation or
Emergency Accreditation will be considered at the discretion of the CEO.
(b) Applications will include a declaration signed by the Medical Practitioner to the effect
that the information provided by the Medical Practitioner is true and correct, that the
Medical Practitioner will comply in every respect with the By-laws in the event that
the Medical Practitioner’s application for Accreditation is approved.
(c) The CEO may interview Medical Practitioners and/or request further information from
applicants that the CEO considers appropriate.
(d) The CEO will ensure that applications are complete and requests for further
information complied with, and upon being satisfied will refer applications, together
with notes from any interview conducted, to the MAAC for consideration.
8.2 Consideration by the Medical Advisory and Audit Committee
(a) The MAAC will consider all applications for Accreditation and Re-Accreditation
referred to it by the CEO.
(b) Consideration by the MAAC will include but not be limited to information relevant to
Credentials, Competence, Current Fitness, Organisational Capability and
Organisational Need.
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(c) The MAAC will make recommendations to the Board as to whether the application
should be approved and if so, on what terms, including the Accreditation Category,
Accreditation Type and Scope of Practice to be granted.
(d) The MAAC will act and make recommendations in accordance with its terms of
reference and any relevant policy, as amended from time to time, including in
relation to the consideration of applications for Accreditation and Re-Accreditation.
(e) In instances where the MAAC has doubts about a Medical Practitioner’s ability to
perform the services, procedures or other interventions which may have been
requested for inclusion in the Scope of Practice, they may recommend to the CEO
to:
(i) initiate an Internal Review;
(ii) initiate an External Review;
(iii) grant Scope of Practice for a limited period of time followed by review;
(iv) apply conditions or limitations to Scope of Practice requested; and/or
(v) apply requirements for relevant clinical services, procedures or other
interventions to be performed under supervision or monitoring.
(f) If the Medical Practitioner’s Credentials and assessed Competence and performance
do not meet the Threshold Credentials (if any) established for the requested Scope
of Practice, the MAAC may recommend refusal of the application.
8.3 Consideration of applications for Initial Accreditation by the Board
(a) The Board will consider applications for initial Accreditation as Medical Practitioners
referred by the MAAC and will decide whether the applications should be rejected or
approved and, if approved, whether any conditions should apply.
(b) In considering applications, the Board will give due consideration to any other
information relevant to the application as determined by the Board, but the final
decision is that of the Board and the Board is not bound by the recommendation of
the MAAC. In addition to considering the recommendations of the MAAC, including
Organisational Capability and Organisational Need, the Board may consider any
matter assessed as relevant to making the determination in the circumstances of a
particular case.
(c) The Board may defer consideration of an application in order to obtain further
information from the MAAC, the Medical Practitioner or any other person or
organisation.
(d) If the Board requires further information from the Medical Practitioner before making
a determination, they will forward a letter to the Medical Practitioner:
(i) informing the Medical Practitioner that the Board requires further information
from the Medical Practitioner before deciding the application;
(ii) identifying the information required. This may include, but is not limited to,
information from third parties such as other hospitals relating to current or
27
past Accreditation, Scope of Practice and other issues relating to or impacting
upon the Accreditation with that other hospital; and
(iii) requesting that the Medical Practitioner provide the information in writing or
consent to contacting a third party for information or documents, together with
any further information the Medical Practitioner considers relevant within
fourteen (14) days from the date of receipt of the letter.
(e) In the event that the information or documents requested by the Board is not
supplied in the time set out in the letter, the Board may, at its discretion, reject the
application or proceed to consider the application without such additional
information.
(f) The Board through the CEO will forward a letter to the Medical Practitioner advising
the Medical Practitioner whether the application has been approved or rejected. If
the application has been approved, the letter will also contain details of the
Accreditation Category, Accreditation Type and Scope of Practice granted.
(g) The Facility Manager will ensure that information relating to Accreditation Category,
Accreditation Type and Scope of Practice is accessible to those providing clinical
services within the Facility.
(h) There is no right of appeal from a decision to reject an application for initial
Accreditation, or any terms or conditions that may be attached to approval of an
application for initial Accreditation.
8.4 Initial Accreditation tenure
(a) Initial Accreditation as a Medical Practitioner at the Facility may, at the election of the
Board, be for a probationary period of one year.
(b) Prior to the end of a probationary period set pursuant to By-Law 8.4(a), a review of
the Medical Practitioner’s level of Competence, Current Fitness, Performance,
compatibility with Organisational Capability and Organisational Need, and
confidence in the Medical Practitioner will be undertaken by the Board. The Board
will seek assistance with the review from the MAAC . The Board may also initiate the
review at any time during the probationary period where concerns arise about
Performance, Competence, Current Fitness of, or confidence in the Medical
Practitioner, or there is evidence of Behavioural Sentinel Events exhibited by the
Medical Practitioner.
(c) In circumstances where, in respect of a Medical Practitioner:
(i) a review conducted by the Board at the end of the probationary period, or
(ii) a review conducted by the Board at any time during the probationary period,
causes the Board to consider:
(iii) the Medical Practitioner’s Scope of Practice should be amended for any
subsequent Accreditation granted, or
(iv) the probationary period should be terminated, or
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(v) the probationary period should be extended, or
(vi) the Medical Practitioner should not be offered further Accreditation,
the Medical Practitioner will be:
(vii) notified of the circumstances which have given rise to the relevant concerns,
and
(viii) be given an opportunity to be heard and present his/her case.
(d) Should the probationary review outcome, including information obtained in
paragraph (c) above, be unacceptable or insufficient to the Board, it may:
(i) amend the Scope of Practice that will granted for any subsequent
Accreditation; or
(ii) reject the continuation of Accreditation.
(e) Should the Medical Practitioner have an acceptable probationary review outcome, or
in circumstances where Initial Accreditation is granted by the Board without a
probationary period, the Board may grant an Accreditation period of up to five (5)
years on receipt of a signed declaration from the Medical Practitioner describing any
specific changes, if any, to the initial information provided and ongoing compliance
with all requirements as per the By-laws.
(f) The Board will make the final determination on Accreditation for all Medical
Practitioners at the end of the probationary period. There will be no right of appeal at
the end of the probationary period for a determination that Accreditation will not be
granted following conclusion of the probationary period, or to any terms or conditions
that may be attached to the grant of any Accreditation following the probationary
period. All Medical Practitioners shall agree with this as a condition of initial
Accreditation.
8.5 Re-Accreditation
(a) The CEO will, at least three months prior to the expiration of any term of
Accreditation of each Medical Practitioner (other than a probationary period), provide
to that Medical Practitioner an application form to be used in applying for Re-
Accreditation.
(b) Any Medical Practitioner wishing to be Re-Accredited must send the completed
application form to the CEO at least two months prior to the expiration date of the
Medical Practitioner’s current term of Accreditation.
(c) The Board, CEO and MAAC will deal with applications for Re-Accreditation in the
same manner in which they are required to deal with applications for initial
Accreditation as Medical Practitioners.
(d) The rights of appeal conferred upon Medical Practitioners who apply for Re-
Accreditation as Medical Practitioners (excepting applications for Accreditation after
the probationary period) are set out in these By-Laws.
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8.6 Re-Accreditation tenure
Granting of Accreditation and Scope of Practice subsequent to the probationary period will be for a term of up to give (5) years, as determined by the Board.
8.7 Nature of appointment
(a) Accreditation does not of itself constitute an employment contract nor does it
establish of itself a contractual relationship between the Medical Practitioner and the
Facility or PresMed Australia.
(b) Accreditation is personal and cannot be transferred to, or exercised by, any other
person.
(c) It is a condition of accepting Accreditation, and of ongoing Accreditation, that the
Accredited Practitioner understands and agrees that these By-laws are the full extent
of processes and procedures available to the Accredited Practitioner with respect to
all matters relating to and impacting upon Accreditation, and no additional procedural
fairness or natural justice principles will be incorporated or implied, other than
processes and procedures that have been explicitly set out in these By-laws.
(d) Accredited Practitioners acknowledge and agree as a condition of the granting of,
and ongoing Accreditation, that the granting of Accreditation establishes only that the
Accredited Practitioner is a person able to provide services at the Facility, as well as
the obligations and expectations with respect to the Accredited Practitioner while
providing services for the period of Accreditation, the granting of Accreditation
creates no rights or legitimate expectation with respect to access to the Facility or its
resources, and while representatives of PresMed Australia and the Facility will
generally conduct themselves in accordance with these By-laws they are not legally
bound to do so and there are no legal consequences for not doing so.
9. Temporary and Emergency Accreditation
9.1 Temporary Accreditation
(a) The CEO may grant Medical Practitioners Temporary Accreditation and Scope of
Practice on terms and conditions considered appropriate by the CEO. Temporary
Accreditation will only be granted on the basis of Patient need, Organisational
Capability and Organisational Need. The CEO may consider Emergency
Accreditation for short notice requests.
(b) Applications for Temporary Accreditation as Medical Practitioners must be made in
writing on the prescribed form. All questions on the prescribed form must be fully
completed and required information and documents submitted before an application
will be considered.
(c) Temporary Accreditation may be terminated by the CEO for failure by the Medical
Practitioner to comply with the requirements of the By-laws or failure to comply with
Temporary Accreditation requirements.
(d) Temporary Accreditation will automatically cease upon a determination of the
Medical Practitioner’s application for Accreditation or at such other time as the CEO
decides.
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(e) The period of Temporary Accreditation shall be determined by the CEO, which will
be for a period of no longer than six (6) months.
(f) There can be no expectation that a grant of Temporary Accreditation will mean that
there is be a subsequent granting of Accreditation.
(g) The MAAC will be informed of all Temporary Accreditation granted.
(h) There will be no right of appeal from decisions relating to the granting of Temporary
Accreditation or termination of Temporary Accreditation.
9.2 Emergency Accreditation
(a) In the case of an emergency, any Medical Practitioner, to the extent permitted by the
terms of the Medical Practitioner’s registration, may request Emergency
Accreditation and granting of Scope of Practice in order to continue the provision of
treatment and care to Patients. Emergency Accreditation may be considered by the
CEO or Facility Manager for short notice requests, to ensure continuity and safety of
care for Patients and/or to meet Organisational Need.
(b) As a minimum, the following is required:
(i) verification of identity through inspection of relevant documents (eg driver’s
licence with photograph);
(ii) contact as soon as practicable with a member of senior management of an
organisation nominated by the Medical Practitioner as their most recent place
of Accreditation to verify employment or appointment history;
(iii) verification of professional registration and insurance as soon as practicable;
(iv) confirmation of at least one professional referee of the Medical Practitioner’s
Competence and good standing;
(v) verification will be undertaken by the CEO or Facility Manager and will be fully
documented.
(c) Emergency Accreditation will be followed as soon as practicable with Temporary
Accreditation or initial Accreditation processes, if required.
(d) Emergency Accreditation will be approved for a limited period as identified by the
CEO or Facility Manager, for the safety of Patients involved, and will automatically
terminate at the expiry of that period or as otherwise determined by the CEO or
Facility Manager.
(e) The MAAC will be informed of all Emergency Accreditation granted.
(f) There will be no right of appeal from decisions on granting, or termination, of
Emergency Accreditation.
9.3 Locum Tenens
Locums must be approved by the CEO or Facility Manager before they are permitted to arrange the admission of and/or to treat Patients on behalf of Medical Practitioners.
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Temporary Accreditation requirements must be met before approval of locums is granted.
There will be no right of appeal from decisions in relation to locum appointments.
10. Variation of Accreditation or Scope of Practice
10.1 Practitioner may request amendment of Accreditation or Scope of Practice
(a) An Accredited Medical Practitioner may apply for an amendment or variation of their
existing Scope of Practice or any term or condition of their Accreditation, other than
in relation to the general terms and conditions applying to all Accredited Practitioners
as provided in these By-laws.
(b) The process for amendment or variation is the same for an application for Re-
Accreditation, except the Medical Practitioner will be required to complete a Request
for Amendment of Accreditation or Scope of Practice Form and provide relevant
documentation and references in support of the amendment or variation.
(c) The process to adopt in consideration of the application for amendment or variation
will be as set out in By-Laws 8.1 to 8.3.
(d) The rights of appeal conferred upon Medical Practitioners who apply for amendment
or variation are set out in these By-Laws, except an appeal is not available for an
application made during a probationary period, or in relation to Temporary
Accreditation, Emergency Accreditation, or a locum tenens.
11. Review of Accreditation or Scope of Practice
11.1 Initiation of Review of Accreditation or Scope of Practice
(a) The Board may at any time initiate a review of a Medical Practitioner’s Accreditation
or Scope of Practice where concerns or an allegation are raised about any of the
following:
(i) Patient health or safety could potentially be compromised;
(ii) the rights or interests of a Patient, staff or someone engaged in or at the
Facility has been adversely affected or could be infringed upon;
(iii) non-compliance with the Behavioural Standards;
(iv) the Medical Practitioner's level of Competence;
(v) the Medical Practitioner's Current Fitness;
(vi) the Medical Practitioner's Performance;
(vii) compatibility with Organisational Capability or Organisational Need;
(viii) the current Scope of Practice granted does not support the care or treatment
sought to be undertaken by the Medical Practitioner;
(ix) confidence held in the Medical Practitioner;
(x) compliance with these By-laws, including terms and conditions;
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(xi) the efficient operation of the Facility could be threatened or disrupted, the
potential loss of the Facility's licence or accreditation, or the potential to bring
the Facility into disrepute;
(xii) a breach of a legislative or legal obligation of the Facility or imposed upon the
Accredited Practitioner may have occurred;
(xiii) a potential ground for suspension or termination of Accreditation; or
(xiv) as elsewhere defined in these By-laws.
(b) A review may be requested by any other person or organisation, including external to
the Facility, however the commencement of a review remains within the sole
discretion of the Board.
(c) The Board will determine whether the process to be adopted is an;
(i) Internal Review; or
(ii) External Review.
(d) Prior to determining whether an Internal Review or External Review will be
conducted, the Board may in its absolute discretion and via a Board nominated
delegate meet with the Medical Practitioner, along with any other persons the Board
considers appropriate, advise of the concern or allegation raised, and invite a
preliminary response from the Medical Practitioner (in writing or orally, as determined
by the Board) before the Board makes a determination whether a review will
proceed, and if so, the type of review.
(e) The review may have wider terms of reference then a review of the Medical
Practitioner's Accreditation or Scope of Practice.
(f) The Board must make a determination whether to impose an interim suspension or
conditions upon the Accreditation of the Medical Practitioner pending the outcome of
the review and, if imposed, there is no right of appeal from this interim decision
pursuant to the By-laws.
(g) In addition or as an alternative to conducting an internal or external review, the
Board will notify the Medical Practitioner's registration board and/or other
professional body responsible for the Medical Practitioner of details of the concerns
raised if required by legislation, otherwise the Board may elect to notify if the Board
considers it is in the interests of Patient care or safety to do so, it is in the interests of
protection of the Public (including patients at other facilities) to do so, or it is
considered that the registration board or professional body is more appropriate to
investigate and take necessary action. Following the outcome of any action taken by
the registration board and/or other professional body the Board may elect to take
action, or further action, under these By-laws.
11.2 Internal Review of Accreditation and Scope of Practice
(a) The Board will establish the terms of reference of the Internal Review, and may seek
assistance from the MAAC or co-opted Medical Practitioners or personnel from
within the Facility or PresMed Australia who bring specific expertise to the Internal
Review as determined by the Board.
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(b) The terms of reference, process, and reviewers will be as determined by the Board.
The process will ordinarily include the opportunity for submissions from the Medical
Practitioner, which may be written and/or oral.
(c) The Board will notify the Medical Practitioner in writing of the review, the terms of
reference, process and reviewers.
(d) A detailed report on the findings of the review in accordance with the terms of
reference will be provided by the reviewers to the Board.
(e) Following consideration of the report, the Board is required to make a determination
of whether or not to continue (including with conditions), amend, suspend or
terminate a Medical Practitioner’s Accreditation in accordance with these By-laws.
(f) The Board must notify the Medical Practitioner in writing of the determination made
in relation to the Accreditation, the reasons for it, and advise of the right of appeal,
the appeal process and the timeframe for an appeal.
(g) The Medical Practitioner shall have the rights of appeal established by these By-laws
in relation to the final determination made by the Board if a decision is made to
amend, suspend, terminate or impose conditions on the Medical Practitioner's
Accreditation.
(h) In addition or as an alternative to taking action in relation to the Accreditation follow
receipt of the report, the Board will notify the Medical Practitioner's registration board
and/or other professional body responsible for the Medical Practitioner of details of
the concerns raised and outcome of the review if required by legislation, otherwise
the Board may elect to notify if the Facility Manager considers it is in the interests of
Patient care or safety to do so, it is in the interests of protection of the Public
(including patients at other facilities) to do so, it is considered appropriate that the
registration board or professional body consider the matter, or it should be done to
protect the interests of the Facility.
11.3 External Review of Accreditation and scope of practice
(a) The Board will make a determination about whether an External Review will be
undertaken.
(b) An External Review will be undertaken by a person(s) external to the Facility,
PresMed Australia and of the Accredited Medical Practitioner in question and such
person(s) will be nominated by the Board at its discretion.
(c) The terms of reference, process, and reviewers will be as determined by the Board.
The process will ordinarily include the opportunity for submissions from the Medical
Practitioner, which may be written and/or oral.
(d) The Board will notify the Medical Practitioner in writing of the review, the terms of
reference, process and reviewers.
(e) The external reviewer is required to provide a detailed report on the findings of the
review in accordance with the terms of reference to the Board.
(f) The Board will review the report from the External Review and make a determination
of whether to continue (including with conditions), amend, suspend or terminate the
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Medical Practitioner’s Accreditation or Scope of Practice in accordance with these
By-laws.
(g) The Board must notify the Medical Practitioner in writing of the determination made
in relation to the Accreditation, the reasons for it, and advise of the right of appeal,
the appeal process and the timeframe for an appeal.
(h) The Medical Practitioner shall have the rights of appeal established by these By-laws
in relation to the final determination made by the Board if a decision is made to
amend, suspend, terminate or impose conditions on the Medical Practitioner's
Accreditation.
(i) In addition or as an alternative to taking action in relation to the Accreditation
following receipt of the report, the Board will notify the Medical Practitioner's
registration board and/or other professional body responsible for the Medical
Practitioner of details of the concerns raised and outcome of the review if required by
legislation, otherwise the Board may elect to notify if the Board considers it is in the
interests of Patient care or safety to do so, it is in the interests of protection of the
Public (including patients at other facilities) to do so, it is considered appropriate that
the registration board or professional body consider the matter, or it should be done
to protect the interests of the Facility.
12. Suspension, termination, imposition of conditions, resignation and expiry of Accreditation
12.1 Suspension of Accreditation
(a) The Board may immediately suspend a Medical Practitioner’s Accreditation should
the Board believe, or have a sufficient concern:
(i) it is in the interests of Patient care or safety. This can be based upon an
investigation by an external agency including a registration board, disciplinary
body, Coroner or health complaints body, and may be related to a patient or
patients at another facility not operated by the Facility;
(ii) the continuance of the current Scope of Practice raises a significant concern
about the safety and quality of health care to be provided by the Medical
Practitioner;
(iii) it is in the interests of staff welfare or safety;
(iv) serious and unresolved allegations have been made in relation to the Medical
Practitioner. This may be related to a patient or patients of another facility not
operated by the Facility, including if these are the subject of review by an
external agency including a registration board, disciplinary body, Coroner or a
health complaints body;
(v) the Medical Practitioner fails to observe the terms and conditions of his/her
Accreditation;
(vi) the behaviour or conduct is in breach of a direction or an undertaking, these
By-laws or PresMed Australia / Facility policies and procedures;
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(vii) the behaviour or conduct is such that it is unduly hindering the efficient
operation of the Facility, is bringing the Facility into disrepute, does not
comply with the Behaviour Standards, is considered disruptive or a
Behavioural Sentinel Event or is inconsistent with the values of the Facility;
(viii) the Medical Practitioner has been suspended by their registration board;
(ix) there is a finding of professional misconduct, unprofessional conduct,
unsatisfactory professional conduct or some other adverse professional
finding (however described) by a registration board or other relevant
disciplinary body or professional standards organisation for the Medical
Practitioner;
(x) the Medical Practitioner's professional registration is amended, or conditions
imposed, or undertakings agreed, irrespective of whether this relates to a
current or former Patient of the Facility;
(xi) the Medical Practitioner has made a false declaration or provided false or
inaccurate information to the Facility, either through omission of important
information or inclusion of false or inaccurate information;
(xii) the Medical Practitioner fails to make the required notifications required to be
given pursuant to these By-laws or based upon the information contained in a
notification suspension is considered appropriate;
(xiii) the Accreditation, clinical privileges or Scope of Practice of the Medical
Practitioner has been suspended, terminated, restricted or made conditional
by another health care organisation;
(xiv) the Medical Practitioner is the subject of a criminal investigation about a
serious matter (for example a drug related matter, or an allegation of a crime
against a person such as a sex or violence offence) which, if established,
could affect his or her ability to exercise his or her Scope of Practice safely
and competently and with the confidence of the Board and the broader
community;
(xv) the Medical Practitioner has been convicted of a crime which could affect his
or her ability to exercise his or her Scope of Practice safely and competently
and with the confidence of the Board and the broader community;
(xvi) based upon a finalised Internal Review or External Review pursuant to these
By-laws any of the above criteria for suspension are considered to apply;
(xvii) an Internal Review or External Review has been initiated pursuant to these
By-laws and the Board considers that an interim suspension is appropriate
pending the outcome of the review; or
(xviii) there are other unresolved issues or other concerns in respect of the Medical
Practitioner that is considered to be a ground for suspension.
(b) The Board shall notify the Medical Practitioner of:
(i) the fact of the suspension;
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(ii) the period of suspension;
(iii) the reasons for the suspension;
(iv) if the Board considers it applicable and appropriate in the circumstances,
invite a written response from the Medical Practitioner, including a response
why the Medical Practitioner may consider the suspension should be lifted;
(v) if Board considers it applicable and appropriate in the circumstances, any
actions that must be performed for the suspension to be lifted and the period
within which those actions must be completed; and
(vi) the right of appeal, the appeal process and the time frame for an appeal.
(c) As an alternative to an immediate suspension, the Board may elect to deliver a show
cause notice to the Medical Practitioner advising of:
(i) the facts and circumstances forming the basis for possible suspension;
(ii) the grounds under the By-Laws upon which suspension may occur;
(iii) invite a written response from the Medical Practitioner, including a response
why the Medical Practitioner may consider suspension is not appropriate;
(iv) if applicable and appropriate in the circumstances, any actions that must be
performed for the suspension not to occur and the period within which those
actions must be completed; and
(v) a timeframe in which a response is required from the Medical Practitioner to
the show cause notice;
Following receipt of the response the Board will determine whether the Accreditation will be suspended. If suspension is to occur notification will be sent in accordance with paragraph (b). Otherwise the Medical Practitioner will be advised that suspension will not occur, however this will not prevent the Board from taking other action at this time, including imposition of conditions, and will not prevent the Board from relying upon these matters as a ground for suspension or termination in the future.
(d) Ordinarily suspension will be suspension of Accreditation in its entirety, however the
Board may determine for a particular case that the suspension will be a specified
part of the Scope of Practice previously granted and these By-laws in relation to
suspension will apply to the specified part of the Scope of Practice that is
suspended.
(e) The suspension is ended either by terminating the Accreditation or lifting the
suspension. This will occur by written notification by the Board.
(f) The affected Medical Practitioner shall have the rights of appeal established by these
By-laws.
(g) If there is held, in good faith, a belief that the matters forming the grounds for
suspension give rise to a significant concern about the safety and quality of health
care provided by the Medical Practitioner including but not limited to patients outside
of the Facility, it is in the interests of Patient care or safety to do so, it is in the
37
interests of protection of the Public (including patients at other facilities) to do so, it is
required by legislation, or for other reasonable grounds, the Board will notify the
Medical Practitioner's registration board and/or other relevant regulatory agency of
the suspension and the reasons for it.
(h) Accredited Practitioners accept and agree that, as part of the acceptance of
Accreditation, a suspension of Accreditation carried out in accordance with these By-
laws is a safety and protective process rather than a punitive process, and as such it
does not result in an entitlement to any compensation, including for economic loss or
reputational damage.
12.2 Termination of Accreditation
(a) Accreditation shall be immediately terminated by the Board if the following has
occurred, or if it appears based upon the information available to the Board the
following has occurred:
(i) the Medical Practitioner ceases to be registered with their relevant registration
board;
(ii) the Medical Practitioner ceases to maintain Adequate Professional Indemnity
Insurance covering the Scope of Practice or or a claim on the Medical
Practitioner’s professional indemnity insurance is denied (whether or not such
claim relates to a Patient of PMA);
(iii) based upon the information contained in a notification required to be given
pursuant to these By-laws, it is considered that continued Accreditation is
untenable;
(iv) based upon a finding of professional misconduct, unprofessional conduct,
unsatisfactory professional conduct or some other adverse professional
finding (however described) by a registration board or other relevant
disciplinary body or professional standards organisation for the Medical
Practitioner and it is considered that continued Accreditation is untenable;
(v) the Medical Practitioner has been convicted of or pleaded guilty to a crime
(excluding a driving offence that does not result in a prison term) and it is
considered that continued Accreditation is untenable or impacts adversely on
the interests of the Facility or PMA;
(vi) a term or condition that attaches to an approval of Accreditation is breached,
not satisfied, or according to that term or condition results in the Accreditation
concluding;
(vii) the Medical Practitioner is not regarded by the Board as having the
appropriate Current Fitness to retain Accreditation or the Scope of Practice, or
the Board does not have confidence in the continued appointment of the
Medical Practitioner;
(viii) conditions have been imposed by the Medical Practitioner's registration board
on clinical practice that restricts practice and the Board elects not to
accommodate the conditions imposed;
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(ix) the Scope of Practice is no longer supported by Organisational Capability or
Organisational Need, including with respect to the services necessary to
support the Scope of Practice; or
(x) a contract of employment or to provide services or shareholding agreement is
terminated or ends, and is not renewed.
(b) Accreditation may be terminated by the Board, if the following has occurred, or if it
appears based upon the information available to the Board the following has
occurred:
(i) based upon any of the matters in By-Law 12.1(a) and it is considered
suspension is an insufficient response in the circumstances;
(ii) based upon a finalised Internal Review or External Review pursuant to these
By-laws and termination of Accreditation is considered appropriate in the
circumstances or in circumstances where the Board does not have
confidence in the continued appointment of the Medical Practitioner;
(iii) the Medical Practitioner has not exercised Accreditation or utilised the
facilities at the Facility for a continuous period of 6 months, or at a level or
frequency as otherwise specified to the Medical Practitioner;
(iv) the Medical Practitioner becomes permanently incapable of performing
his/her duties which shall for the purposes of these By-laws be a continuous
period of six months’ incapacity; or
(v) there are other unresolved issues or other concerns in respect of the Medical
Practitioner that is considered to be a ground for termination.
(c) The Accreditation of a Medical Practitioner may be terminated as otherwise provided
in these By-laws.
(d) The Board shall notify the Medical Practitioner of:
(i) the fact of the termination;
(ii) the reasons for the termination;
(iii) if the Board considers it applicable and appropriate in the circumstances,
invite a written response from the Medical Practitioner why they may consider
a termination should not have occurred; and
(iv) if a right of appeal is available in the circumstances, the right of appeal, the
appeal process and the time frame for an appeal.
(e) As an alternative to an immediate termination, the Board may elect to deliver a show
cause notice to the Medical Practitioner advising of:
(i) the facts and circumstances forming the basis for possible termination;
(ii) the grounds under the By-Laws upon which termination may occur;
(iii) invite a written response from the Medical Practitioner, including a response
why the Medical Practitioner may consider termination is not appropriate;
39
(iv) if applicable and appropriate in the circumstances, any actions that must be
performed for the termination not to occur and the period within which those
actions must be completed; and
(v) a timeframe in which a response is required from the Medical Practitioner to
the show cause notice;
Following receipt of the response the Board will determine whether the Accreditation will be terminated. If termination is to occur notification will be sent in accordance with paragraph (d). Otherwise the Medical Practitioner will be advised that termination will not occur, however this will not prevent the Board from taking other action at this time, including imposition of conditions, and will not prevent the Board from relying upon these matters as a ground for suspension or termination in the future.
(f) For a termination of Accreditation pursuant to By-law 12.2(a), there shall be no right
of appeal.
(g) For a termination of Accreditation pursuant to By-law 12.2(b), the Medical
Practitioner shall have the rights of appeal established by these By-laws.
(h) Unless it is determined not appropriate in the particular circumstances, the fact and
details of the termination will be notified by the Board to the Medical Practitioner's
registration board and/or other relevant regulatory agency.
(i) Accredited Practitioners accept and agree, as part of the acceptance of
Accreditation, that a termination of Accreditation carried out in accordance with these
By-laws is a safety and protective process rather than a punitive process, and as
such it does not result in an entitlement to any compensation, including for economic
loss or reputational damage.
(j) As a separate right and despite anything set out above in By-law 12.2, the CEO may
terminate the Accreditation of an Accredited Practitioner without being required to
provide reasons, by ordinarily providing no less than three (3) months written notice,
or such other shorter or longer period as the CEO considers reasonable in the
circumstances. There will be no right of appeal pursuant to these By-laws from such
a decision of the CEO.
12.3 Imposition of conditions
(a) At the conclusion of or pending finalisation of an Internal or External Review, or in
lieu of a suspension, or in lieu of a termination, the Board may elect to impose
conditions on the Accreditation or Scope of Practice.
(b) The Board must notify the Medical Practitioner in writing of the imposition of
conditions, the reasons for it, the consequences if the conditions are breached, and
advise of the right of appeal, the appeal process and the timeframe for an appeal.
(c) If the Board considers it applicable and appropriate in the circumstances, they may
also invite a written response from the Medical Practitioner as to why the Medical
Practitioner may consider the conditions should not be imposed.
(d) If the conditions are breached, then suspension or termination of Accreditation may
occur, as determined by the Board.
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(e) The affected Medical Practitioner shall have the rights of appeal established by these
By-laws.
(f) If there is held, in good faith, a belief that the continuation of the unconditional right
to practise in any other organisation would raise a significant concern about the
safety and quality of health care for patients and the public, the Board will notify the
Medical Practitioner's registration board and/or other relevant regulatory agency of
the imposition of the conditions and the reasons the conditions were imposed.
(g) Accredited Practitioners accept and agree, as part of the acceptance of
Accreditation, that an imposition of conditions carried out in accordance with these
By-Laws is a safety and protective process rather than a punitive process, and as
such it does not result in an entitlement to any compensation, including for economic
loss or reputational damage.
12.4 Resignation and expiry of Accreditation
A Medical Practitioner may resign his/her Accreditation by giving one month's notice of the intention to do so to the Board, unless a shorter notice period is otherwise agreed by the Board.
A Medical Practitioner who intends to cease treating Patients either indefinitely or for an extended period must notify his/her intention to the Board, and Accreditation will be taken to be withdrawn one month from the date of notification unless the Board decides a shorter notice period is appropriate in the circumstances.
If an application for Re-Accreditation is not received within the timeframe provided for in these By-laws, unless determined otherwise by the Board, the Accreditation will expire at the conclusion of its term. If the Medical Practitioner wishes to admit or treat Patients at the Facility after the expiration of Accreditation, an application for Accreditation must be made as an application for initial Accreditation.
If the Medical Practitioner's Scope of Practice is no longer supported by Organisational Capability or Organisational Need, if the Medical Practitioner will no longer be able to meet the terms and conditions of Accreditation, or where admission of Patients or utilisation of services at the Facility is regarded by the Board to be insufficient, the Board will raise these matters in writing with the Accredited Practitioner and invite a meeting to discuss. Following the meeting the Board and Accredited Practitioner may agree that Accreditation will expire and they will agree on the date for expiration of Accreditation. Following the date of expiration, if the Medical Practitioner wishes to admit or treat Patients at the Facility, an application for Accreditation must be made as an application for initial Accreditation.
The provisions in relation to resignation and expiration of Accreditation in no way limit the ability of the Board to take action pursuant to other provisions of these By-laws, including by way of suspension or termination of Accreditation.
13. Appeal rights and procedure
13.1 Rights of appeal against decisions affecting Accreditation
(a) There shall be no right of appeal against a decision to not approve initial
Accreditation, Temporary Accreditation, Emergency Accreditation, a locum
appointment, or continued Accreditation at the end of a probationary period or
Temporary Accreditation, Emergency Accreditation or locum period.
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(b) Subject to paragraph a) above, a Medical Practitioner shall have the rights of appeal
as set out in these By-Laws.
13.2 Appeal process
(a) A Medical Practitioner shall have fourteen (14) days from the date of notification of a
decision to which there is a right of appeal in these By-Laws to lodge an appeal
against the decision.
(b) An appeal must be in writing to the CEO and received by the CEO within the
fourteen (14) day appeal period or else the right to appeal is lost.
(c) Unless decided otherwise by the CEO in the circumstances of the particular case,
which will only be in exceptional circumstances, lodgement of an appeal does not
result in a stay of the decision under appeal and the decision will stand and be
actioned accordingly.
(d) The CEO will nominate an Appeal Committee to hear the appeal, establish terms of
reference, and submit all relevant material to the chairperson of the Appeal
Committee.
(e) The Appeal Committee shall comprise at least three (3) persons and will include:
(i) a nominee of the CEO, who may be an Accredited Practitioner, who must be
independent of the decision under appeal regarding the Medical Practitioner,
and who will be the chairperson of the Appeal Committee;
(ii) a nominee of the Board, who may be an Accredited Practitioner, and who
must be independent of the decision under appeal regarding the Medical
Practitioner;
(iii) any other member or members who bring specific expertise to the decision
under appeal, as determined by the CEO, who must be independent of the
decision under appeal regarding the Medical Practitioner, and who may be an
Accredited Practitioner. The CEO in their complete discretion may invite the
appellant to make suggestions or comments on the proposed additional
members of the Appeal Committee (other than the nominees in (i) and (ii)
above), but is not bound to follow the suggestions or comments.
(f) Before accepting the appointment, the nominees will confirm that they do not have a
known conflict of interest with the appellant and will sign a confidentiality agreement.
Once all members of the Appeal Committee have accepted the appointment, the
CEO will notify the appellant of the members of the Appeal Committee.
(g) Unless a shorter timeframe is agreed by the appellant and the Appeal Committee,
the appellant shall be provided with at least 14 days' notice of the date for
determination of the appeal by the Appeal Committee. The notice from the Appeal
Committee will ordinarily set out the date for determination of the appeal, the
members of the Appeal Committee, the process that will be adopted, and will invite
the appellant to make a submission about the decision under appeal. Subject to an
agreement to confidentiality from the appellant, the chairperson of the Appeal
Committee may provide the appellant with copies of material to be relied upon by the
Appeal Committee.
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(h) The appellant will be given the opportunity to make a submission to the Appeal
Committee. The Appeal Committee shall determine whether the submission by the
appellant may be in writing or in person or both.
(i) If the appellant elects to provide written submissions to the Appeal Committee,
following such a request from the Appeal Committee for a written submission, unless
a longer time frame is agreed between the appellant and Appeal Committee the
written submission will be provided within 7 days of the request.
(j) A nominee of the Board may present to the Appeals Committee in order to support
the decision under appeal.
(k) If the appellant attends before the Appeal Committee to answer questions and to
make submissions, the appellant is not entitled to have formal legal representation at
the meeting of the Appeal Committee. The appellant is entitled to be accompanied
by a support person, who may be a lawyer, but that support person is not entitled to
address the Appeal Committee.
(l) The appellant shall not be present during Appeal Committee deliberations except
when invited to be heard in respect of his/her appeal.
(m) The chairperson of the Appeal Committee shall determine any question of procedure
for the Appeal Committee, with questions of procedure entirely within the discretion
of the chairperson of the Appeal Committee.
(n) The Appeal Committee will make a written recommendation regarding the appeal to
the CEO, including provision of reasons for the recommendation. The
recommendation may be made by a majority of the members of the Appeal
Committee and if an even number of Appeal Committee members then the
chairperson of the Appeal Committee has the deciding vote. A copy of the
recommendation will be provided to the appellant.
(o) The CEO will consider the recommendation of the Appeal Committee and make a
decision about the appeal.
(p) The decision of the CEO will be notified in writing to the appellant.
(q) The decision of the CEO is final and binding, and there is no further appeal allowed
under these By-Laws from this decision.
(r) If a notification has already been given to an external agency, such as a registration
Board, then the CEO will notify that external agency of the appeal decision. If a
notification has not already been given, the CEO will make a determination whether
notification should now occur based upon the relevant considerations for notification
to an external agency as set out in these By-laws relating to the decision under
appeal.
Part D – Accreditation of Dentists
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14. Accreditation and Scope of Practice of Dentists
By-laws 7 to 13 are hereby repeated in full substituting where applicable Dentist for Medical Practitioner.
Applications for Initial Accreditation and Re-Accreditation should be submitted on the relevant form to the CEO.
Part E– Accreditation of Visiting Allied Health Professionals
15. Accreditation and Scope of Practice of Visiting Allied Health Professionals
This By-law 15 may also be utilised for other health practitioners who do not fall into the category of Medical Practitioner or Dentist, with the process as modified by the CEO to suit the particular circumstances of the case.
Applications for Initial Accreditation and Re-Accreditation should be submitted on the relevant form to the CEO.
By-laws 7 to 13 are hereby repeated in full substituting where applicable health practitioner for Medical Practitioner.
Part F – Amending By-laws, annexures, and associated policies and procedures, and other matters
16. Amendments to, and instruments created pursuant to, the By-laws
(a) Amendments to these By-laws can only be made by approval of the CEO.
(b) All Accredited Practitioners will be bound by amendments to the By-laws from the
date of approval of the amendments by the CEO, even if Accreditation was obtained
prior to the amendments being made.
(c) The CEO may approve any annexures that accompany these By-Laws, and
amendments that may be made from time to time to those annexures, and the
annexures once approved by the CEO are integrated with and form part of the By-
Laws. The documents contained in the annexures must be utilised and are intended
to create consistency in the application of the processes for Accreditation and
granting of Scope of Practice.
(d) The CEO may approve forms, terms of reference and policies and procedures that
are created pursuant to these By-Laws or to provide greater detail and guidance in
relation to implementation of aspects of these By-Laws. These may include but are
not limited to Accreditation and Scope of Practice requirements and the further
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criteria and requirements will be incorporated as criteria and requirements of these
By-laws.
17. Audit and Compliance
The Board will establish a regular audit process, at intervals determined to be appropriate by the Board or as may be required by a regulatory authority, to ensure compliance with and improve the effectiveness of the processes set out in these By-Laws relating to Credentialing and Accreditation, and any associated policies and procedures, including adherence by Accredited Practitioners to approved Scope of Practice.
The audit process will include identification of opportunities for quality improvement in the Credentialing and Accreditation processes that will be reported to the CEO.
